Responsibility Statement:
Your insurance is a method for you to receive reimbursement for fees you have paid to the optometrist for services rendered. Having Insurance is not a substitute for payment. Many companies have fixed allowances or percentages based on your contract with them not with our office. It is your responsibility to pay in advance for the deductible, coinsurance, or any other balances not paid by your insurance. We will assist you in receiving reimbursement as much as possible, but you are responsible in advance for your bill.

Financial Responsibility:
By signing this statement, you agree to be financially responsible for all charges. I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the doctor or doctor’s group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I also agree to be responsible for attorney fees and costs of collection in the event of default.

Authorization to Release Medical Information:
I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine benefits or the benefits payable for related services. This assignment will remain in effect until revoked in writing. A photocopy of this assignment is considered to be as valid as the original.

Assignment of Benefits:
Assignment of Benefits Authorization and Release of Medical Information I authorize all payments from my insurance carrier to be made directly to Dry Eye Healing Institute. I certify that the information I reported with regard to my insurance coverage is correct. I further authorize the release of any information for this or any related claim to my insurance company and will permit a copy of this form to be used in place of the original.